t bears repeating some of the facts and statistics reviewed in Module 1, with respect to vertebral fractures in particular:
It has also been noted that more than 60% of vertebral fractures are ‘silent’ in nature, that is not accompanied by any overt pain or immediate structural changes20. Even more striking is that while these are by far the most common type of fracture in osteoporotic population, the majority (66%) do not gain clinical attention.47
There are four easy, clinical measures that can help identify these silent fractures.
As the name suggests, this refers to the amount of height that an individual has lost over his or her lifetime. Simply calculate the difference between a person’s tallest height recalled against their current measured height.
Ensure accurate current height measures by:
Practice guidelines suggest that individuals over age 60 with >6cm HHL and individuals under age 60 with >4cm HHL be referred for spine radiographs as this is indicative of present vertebral fractures.
For patients being followed over time by a clinician, changes in height between subsequent visits can be monitored (up to a 3-year time frame).
Presence of vertebral fractures is indicated with a loss of >2cm PHL measure.
This measure is useful in the presence of frank or developing kyphosis. Since postural compensatory changes may be present, it is important to reveal the upper back, and position the patient against the wall such that:
WOD greater than 5 cm is indicative of a vertebral fracture likely present in the thoracic spine.
Vertebral fractures in the lumbar spine can also cause postural changes and compensations. The distance between the ribs and pelvis (iliocostal distance) can be measure to assess this postural change. In order to measure this:
An RPD of less than 2 fingerbreadths or 3.6cm suggests the presence of a vertebral fracture, likely in the lumbar region.
Adapted from two articles by Kerry Siminoski MD published in the Spring & Winter 2005 issues of Osteoporosis Update.47
No single physical exam finding can rule in osteoporosis or fracture without further testing. The above measures are easy clinical tests which would identify patients who may benefit from early screening/BMD testing.
Osteoporosis Canada has provided guidelines for BMD testing (outlined in detail in Module 1). In brief, the following can be applied:
In addition, the following two tools have been identified in current research9 to be sensitive and valid in assisting the clinician to make decisions regarding BMD testing.
Calculation of score – points given for:
Interpretation of score:
(Cadarette, 2000; Development and validation of ORAI)
Calculation of score:
Interpretation of score:
(Koh, 2001; A simple tool to identify Asian women at risk of OP)